Specific, tailored support for Long Term Conditions

Including supportive self-management and shared decision making to develop a self-management plan (with contingency planning) optimising falls and immobility, medicine/polypharmacy and mental health.

What works

  • Involve everyone in co-ordinating  support.
  • Offer education tailored to need and literacy.
  • Consider TECS to self-manage long-term condition(s).
  • Consider personal care budgets and direct payments.
  • Offer support and care planning for multiple morbidity and frailty (inline with PCN contract on personal care and anticipatory planning)
  • Screen and advise about falls, encouraging strength and balance training
  • Tackle polypharmacy with specialist pharmacists (e.g. SMR in line with PCN contract)
  • Identify and manage depression and anxiety, linking to community services and VCSE

  • SSM improves a person’s knowledge about their conditions, coping ability and use of health care.
  • Streamlined management of LTCs.
  • Fewer unnecessary GP appointments.
  • Fewer medicines prescribed, adverse drug reactions and hospitalisation (adverse reactions).
  • Improve medication use (when staff trained in SMR receive training).
  • Reduce the risk of falls.

Evidence summaries

National Voices. Supportive self-management. Summarising the evidence from literature reviews – https://www.nationalvoices.org.uk/sites/default/files/public/publications/supporting_self-management.pdf

Advantage – management of frailty at an individual level: Systematic review – http://advantageja.eu/images/WP6-Managing-frailty-atindividual-level-a-Systematic-Review.pdf

Polypharmacy BEERS – http://patientsafety.pa.gov/ADVISORIES/documents/200512_11.pdf

Impact and Measures

We know that frailty has a significant impact of people, populations and health and care systems. Frail older people are highly susceptible to adverse health outcomes, such as falls, disabilities, institutionalisation, hospitalisation and death. However, trying to understand this impact on populations and health and care system is challenging due poor recording of frailty status and the lack of information sharing and interoperability that exists. The following examples of impact are guestimates based on current intelligence.


  • Potential Impact
    • In the North East and North Cumbria region, nearly 10, 000 more people may progress to mild frailty as a result of increasing diagnoses of hypertension
  • Potential measures
    • People aged 65 years and over with 10 or more unique medications
    • Dementia: 65+ years old estimated diagnosis rate
    • The proportion of people (aged 65+ years) who use services who have control over their daily life


For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures in ‘word version of draft frailty toolkit’ page 67.